Congratualtions to this year's winner of the Golden Goniometer

To the Dominican, and Beyond!

A little over a year and a half ago my class was approached with the opportunity to travel to the Dominican Republic to assist the people there with any physical concerns we could. As a part of a team from Northwoods Church teaming with Solid Rock Missions, we would travel down for a week long medical mission trip. I jumped at the chance to not only serve the people there but also to gain more practice in using the skills I'm learning in PT school.

During our preparation time, the earthquake that shook Haiti to crumbles put a change in our plans. Now, instead of only going to the Dominican, some of our group would travel to Haiti as well. The town where Solid Rock had contacts is only a few hours away from the border to Haiti. This provided an easy starting point to bring physical therapy assistance to the people suffering from that tragic day in Port Au Prince.

I was part of the group that stayed in the Dominican for our trip. The guesthouse we stayed in is part of a compound that built a clinic where patients could travel from all around to receive chiropractic, medical, and dental care from us. The physical therapy aspect was actually served at a local clinic.

There we had the opportunity to evaluate and treat patients that had traveled from as far as 3 hours just to be seen once. The main therapist from the clinic said people were lined up the day before we arrived because they were so anxious to get treatment from us. The limited time we spent with them was truly life changing, for both parties involved.

Since we have been back, I know I have been thinking about returning. The trips through Northwoods have been so full, we Bradley students did not have a chance to go this last time. We still wanted to help out in anyway we can. Last weekend we performed with a band our professors are a part of to put on a benefit concert for Solid Rock Missions. So half a dozen PT students put on our musician hats and covered ten songs. During our set, we passed around a donation bucket encouraging people to donate to a good cause. We were able to raise over $300 from just one night of fun.

In addition to helping the people in the Dominican, this trip also helped us sharpen our skills. We had just been learning techniques we were able to apply directly to patients. We were also more comfortable with direct patient contact due to more experience in this area. This inspired us to bring a little of the Dominican home to us.

Around this same time there was an article published talking about Student Led Pro-Bono PT clinics. This was very encouraging to us because we felt we could do something similar. We wanted to be able to provide services to people who need it, while at the same time sharpening our clinic skills, just like we did in the Dominican. This idea had already been brewing in our department director's mind, so when we brought it up it was very well received.

At this time, we are working to partner with Heartland Community Clinic in Peoria to allow us to provide some of those PT services to people who cannot otherwise receive it. We are not trying to compete with area businesses, but rather provide services to patients who perhaps do not have insurance coverage or have met their maximum benefits.

This project will take a lot of dedication from both the students and faculty involved. Having this partnership form will hopefully lead to a continual relationship between the Bradley PT department and Heartland that will foster leadership and growth in the PT students while providing care to the underserved in the Peoria community.

Fall 2010 Golden Goniometer

And this year's winner of the Golden Goniometer goes to EJ Hodel, Meg Martindale, Angela Boundy and Natalie Larsen for their work on the Ottawa Ankle Rules. Congratulations, gang! Well done!

AAOMPT Conference--San Antonio

Keith Scott and I, 3rd year students, just returned from this year's AAOMPT conference in San Antonio. We were there to do a poster presentation which entailed judges evaluating our study and 56 others. Talk about feeling like you're in the midst of a practical!

Anyway, I wanted to talk about how invaluable of an experience the conference was. But in order for you to fully realize how much this conference affected me, allow me to share a little about my background. I have been a chiropractor since 2002 and had decided in 2007 to go back to school for PT for many reasons. I have always been drawn to orthopedics, obviously, but was never really drawn to evidence-based practice; until spine class in the summer of 2009. Joe and Cheryl's class opened my eyes to EBP in a way that has clinically changed the way I will practice from now on. Basing my clinical decision making on the evidence rather than on what a guru says has truly given me confidence with patients that I never really had before. I have become a certified evidence junkie. I subscribe to 2 "push" services and can't get enough. One of the consistent patterns that I am seeing in the literature is that more and more studies are pointing to the efficacy of combining manipulation and exercise. I digress. Back to the conference.

AAOMPT Conference
Friday's keynote address speakers: Stanley Herring, MD; Chad Cook PT, PhD, MBA, OCS, FAAOMPT; Josh Cleland, PT, PhD.

Herring systematically laid out arguments for positioning PT as a first line of defense for musculoskeletal conditions and how we as a nation have spent disgusting amounts of money at improving spine care with little to no improvement in outcomes (cost has mounted as quality has declined).

Cook has authored many research articles, written or contributed to multiple texts, and is editor of the Journal of Manual and Manipulative Therapeutics (JMMT). His keynote address was on the best test for diagnosis of the spine and why its important. In his address he discusses the importance of differential diagnosis, diagnostic accuracy, and the best tests for diagnosis. He discussed the importance of the reference standard that is used to compared the proposed test and how it can make or break the validity of the test. Surprisingly, there are relatively few tests that have withstood the rigors of statistical analysis.

Cleland's talk was entitled "Manual Therapy: if it works, why isn't everyone doing it?" He discussed the evidence for manual therapy and the barriers that PT's need to overcome to incorporate it into their practice.

That was just Friday's addresses. There were breakout sessions all day Saturday as well, and into Sunday morning. All in all the talks were very dynamic and informative. They also had the student special interest group (sSIG) there to get the students more involved. There were exhibitors on hand with everything from rehab products to fellowship programs to journals....free pens galore.

It was such an incredible experience being around some of the greats in the research world. After seeing some of the same names over and over in the literature and then to finally see them in person it was definitely a room full of rock stars.

If you've made it this far I hope to end with one final note of encouragement: get involved. Joe and Cheryl have brought to Bradley an incredible enthusiasm for evidence-based practice. In the (near) future there will be many opportunities to improve your hands-on skills. Keep an eye out for the manual therapy club (coming up yet in Oct), Explain Pain seminar (spring 2011), and the AAOMPT student special interest group (sSIG) on campus (in progress).

As an additional plug for the manual therapy club, if you know that you're leaning toward orthopedics, specifically manual therapy PT, I'd remind you that it's a skill that must be practiced hundreds of times to develop the motor pattern. In chiropractic school we had about a year and a half of manipulation training and admittedly I wasn't completely comfortable for at least a year in practice. I can't stress enough the importance of getting your hands on willing participants. Get your fears out of the way now so you become proficient at it and can confidently treat patients using the best evidence. Hope to see you at the club meeting...

BU DPT 5k

Like to run? Prefer to walk? You can do both!

The BUDPT 5k will be held on September 25th, 2010 @ 9:00 a.m.

The Doctor of Physical Therapy Class of 2012 is sponsoring a 5k walk/run to help raise money for a variety of events. The money raised will defray some of the costs associated with traveling to our national conference in February 2011 and graduation expenses.

Please support the Department of Physical Therapy and run or walk in the 5k. Set a new PR on this flat, fast course! You will have the opportunity to win prizes and all will receive a t-shirt.

Register by September 17th. Registration is $15 for students, $20 for non-students. Click here to download the registration form.

Also available soon: Class of 2012 cookbooks featuring our favorite family recipes!! Please contact dmcooper@mail.bradley.edu for more information.

CSM revisited: Head trauma types: Blunt Force, Acceleration/Deceleration, and Blast

The Federal section of the APTA works to provide support for those who deliver quality physical therapy in Federal Medical facilities. As one can imagine, these PTs spend much of their time working with war veterans, many who have had a traumatic brain injury along with other injuries. The course at CSM was listed as “Balance at a high level: Vestibular training for the Amputee.” While much of the vestibular training is commonly used, the reason why these men with amputations require vestibular training is unusual. Kim Gottshall, PT, PhD, ATC and retired Colonel, US Army Reserves presented this training on this topic to about 150 PTs and PTAs at CSM. The information focused mostly on mild traumatic brain injuries and common associated symptoms.
The fact is blast type head injuries are fairly new. With new technology in body armor, the thorax is protected saving the life of the soldier, and helmets provide some protection from blunt force trauma and/or coup-countercoup (acceleration/deceleration) type head injuries. However, the blast type head injury, created by the shock-wave of the blast is different, and very little study has been done on this topic. The study of the other two types has been building for two to three decades, and there may be little to correlate with blast injuries.
In addition to body armor technology, the other factors that lead to this “signature” injury of the current two wars (Iraq and Afghanistan) is that much of the warfare is urban, as well as that improvised explosive devices are the weapons of choice for the opposition. The shock wave effect creates a sheering injury in the vestibular end organs, as well as a significant release of excitatory neurotransmitters. The result is oxidative cellular stress and direct stimulation of apoptotic pathways. Part of the presentation, then, is multiple site involvement. This means that there may be peripheral and central damage and resulting symptoms. Also common are cognitive difficulty and hearing loss or tinnitus. “Dizziness” is often reported as well, but the type and quality of the dizziness associated with blast injuries is still not characterized.
With lack of clinical research in this area, the current suggestions are to recognize that the neurological exam may result in findings that do not fall into a known pattern and to be as thorough as possible. In addition, quantifiable testing is helpful, such as using computerized dynamic posturography and VOR equipment if available. There are four suggested groups: 1. Post traumatic positional vertigo. 2. Post traumatic exertional dizziness. 3. Post traumatic migraine associated dizziness. 4. Post traumatic spatial disorientation. Blast head injuries also tend to have more cognitive difficulty and more hearing loss along with these different combinations of diagnoses.
Rehabilitation should be focused on the results of the examination. Video was shown and those with amputations were able to complete even the highest demands of rehabilitation with the prosthesis. Dr. Gottshall reported a study that she recently completed. While the exact study methods and procedures were not outlined, several notes were made about the subjects. The main observation was that cognitive rehabilitation seemed to correlate positively with vestibular rehabilitation. In addition, patients perceived improvement before functional gains were made. Finally, there is a temporal component to vestibular rehabilitation.
I look forward to seeing the published studies to come on the nature and sequelae of blast head injuries. For more information about the Federal section of the APTA: http://www.federalpt.org/ A full text article on what is known about
blast head injuries can be found at: http://www.pdhealth.mil/nlAttachments/DHCC-Uploads/21769.Taber.et.al.06.J.Neuropsych.Clin.Neurosci.Blast-rel.TBI.pdf

For other resourses, you can contact me at aalton@mail.bradley.edu

Sensory deficits post stroke

CSM revisit: Sensory deficits post stroke: best practice treatment
Jane E. Sullivan, PT, DHS from Northwestern University presented compelling evidence that Physical therapists need to be treating sensory dysfunction after stroke (Post Stroke Sensory Dysfunction, or PSSD). First, this is truly common, although it is rarely addressed by PT outside of proprioception (where is your arm? Are you sitting up straight? Where are your feet? Etc). In addition, the loss patterns do not follow motor loss patterns, and so these do need to be tested.
A study done by Connell in 2008 found that there was high agreement between different body areas for each modality, but there was low agreement between modalities in each area! This means PTs need to test each modality. Tyson et al in 2007 found that stroke severity and weakness are significantly correlated with PSSD, a finding later corroborated by Connell in 2008.
Also correlated with decreased sensory were outcomes such as increased length of stay, decreased bowel/bladder independence, decreased ability to perform ADL’s, etc. There were many studies cited in this presentation which link low sensory function with discharge placement, slow recovery of motor function, and even mortality.
The good news is this: the neurological system is moldable and trainable. We know that motor patterns can be learned; so too can sensory. There is natural recovery, anatomical redundancy, and bilateral pathways all improve the prognosis.
The reliability and validity of sensory tests were explored, and while there are some issues in this area, the following recommendations were made: 1. Screen everyone (post-stroke) for all modalities including stereognosis. 2. Formally test if linked to movement dysfunction and goals. 3. Standardize your exam.
Obviously, there is a need for more research, but there are promising studies that link improved upper extremity sensation with improved balance outcomes. Electrical stimulation studies have shown excellent potential for “waking up” the sensory system, with improvements noted in spasticity, force, perception, selective movement, as well as balance and gait. Vibration, thermotherapy, intermittent compression, graphesthesia and discrimination tasks and passive movement all show improvement (passive range of motion shows fMRI but not clinical improvement). Finally, these changes persist! There is yet to be any meaningful dose-response trial, however.
The parameters recommended at this time across interventions are: Brief (20-30 min – they will get tired!), and repetitive (3-5 days per week) for several weeks. With any of these treatments, practice mastered tasks first and last, take breaks, and aim for limbic involvement and active attention. Reduce the stress in the environment so the patient may attend to the task as well. A quiet nervous system will respond more dramatically to changes, and above all, PRACTICE!
** for references feel free to contact me at aalton@mail.bradley.edu